Update COPD 2011 – Was ist neu?

 

 Buy Article Permissions and Reprints

Im letzten Jahr waren im Bereich der COPD (chronisch obstruktive Lungenerkrankung) eine ganze Reihe interessanter Entwicklungen zu verzeichnen. Durch Weiterentwicklung von Klassifikationssystemen (BODE-Index) ist es gelungen, die Mortalität von COPD-Patienten wesentlich besser vorherzusagen als bisher. In der medikamentösen Therapie hat sich bei häufigen Exazerbationen, die oft zu Krankenhausaufenthalten führen, der erste 2010 zugelassene Vertreter der Substanzgruppe der Phosphodiesterase-4-Inhibitoren Roflumilast als interessant gezeigt. Das erste über 24 Stunden wirksame inhalierbare Beta-2-Mimetikum Indacaterol erweitert die medikamentösen Therapiemöglichkeiten zusätzlich. Zu den nicht-medikamentösen Therapieoptionen zählen die Lungenvolumenreduktion sowie moderne endoskopische Techniken zur Therapie des Lungenemphysems, ebenso wie die wichtige chronische nicht-invasive Beatmungstherapie. Eine weitere nicht-medikamentöse COPD-Therapie, die einen etwas ungewöhnlichen Ansatz verfolgt, ist die Implantation einer peripheren AV-Fistel, die letztlich wie ein Dialyse-Shunt funktioniert. Die Therapie ist in Deutschland bereits zugelassen, wird momentan jedoch ausschließlich im Rahmen von Studien angewendet.

The field of COPD has faced several new and interesting developments in the past year. Predictions based on the updated BODE index match observed mortality better than before. Several studies suggest a susceptibility phenotype: frequent inflammatory symptoms like chronic cough and sputum production are associated with more exacerbations per year. Since exacerbations frequently lead to hospitalization and increase mortality, there is a necessity to use all means to reduce exacerbation frequency in COPD patients. The phosphodiesterase-4-inhibitor Romflumilast is a new medication to lower the frequency of exacerbations. Another expansion of therapeutic options in COPD is the first once-daily, long acting inhaled beta-2-agonist Indacaterol. After 12 weeks treatment, FEV₁ was significantly improved compared to placebo. New data show a strong association between adherence to inhaler-therapy and mortality. However, mortality was also decreased with adherence to placebo. This gives strong evidence for a “healthy adherer effect”.

Non-medication strategies such as lung volume reduction surgery, new endoscopic techniques, and noninvasive ventilation are described elsewhere in this issue. A unique new approach in COPD-therapy is the implantation of an arteriovenous fistula with left-to-right shunt. The shunt increases mixed venous oxygen content and cardiac output. The fistula is created in the iliofemoral region by a minimally invasive approach whereby an anastomotic vascular clip device is deployed. At this time, this therapy is exclusively available within controlled studies.

Literatur

• 1 Celli BR, Cote CG, Marin JM et al.. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease.  N Engl J Med. 2004;  350 1005-1012
  CrossrefPubMedGoogle Scholar
• 2 Jerrentrup A, Wagner M, Ficker J et al.. Interim results on European multi-center trial to evaluate the clinical utility of arteriovenous ?stulae for treatment of severe COPD.  ERS. 2010;  3419
  PubMedGoogle Scholar
• 3 Puhan MA, Garcia-Aymerich J, Frey M et al.. Expansion of the prognostic assessment of patients with chronic obstructive pulmonary disease: the updated BODE index and the ADO index.  Lancet. 2009;  74 04-711
  PubMedGoogle Scholar
• 4 Burgel PR, Nesme-Meyer P, Chanez P et al.. Cough and sputum production are associated with frequent exacerbations and hospitalizations in COPD subjects.  Chest. 2009;  135 975-982
  CrossrefPubMedGoogle Scholar
• 5 Hurst JR, Vestbo J, Anzueto A et al.. Susceptibility to exacerbation in chronic obstructive pulmonary disease.  N Engl J Med. 2010;  363 1128-1138
  CrossrefPubMedGoogle Scholar
• 6 Calverley PM, Rabe KF, Goehring UM et al.. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials.  Lancet. 2009;  374 685-694
  CrossrefPubMedGoogle Scholar
• 7 Calverley PM, Sanchez-Toril F, McIvor A et al.. Effect of 1-year treatment with roflumilast in severe chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2007;  176 154-161
  CrossrefPubMedGoogle Scholar
• 8 Donohue JF, Fogarty C, Lotvall J et al.. Once-daily bronchodilators for chronic obstructive pulmonary disease: indacaterol versus tiotropium.  Am J Respir Crit Care Med. 2010;  182 155-162
  CrossrefPubMedGoogle Scholar
• 9 van Noord JA, Aumann JL, Janssens E et al.. Comparison of tiotropium once daily, formoterol twice daily and both combined once daily in patients with COPD.  Eur Respir J. 2005;  26 214-222
  CrossrefPubMedGoogle Scholar
• 10 Vogelmeier C, Buhl R, Criee CP et al.. Guidelines for the diagnosis and therapy of COPD issued by Deutsche Atemwegsliga and Deutsche Gesellschaft fur Pneumologie und Beatmungsmedizin.  Pneumologie. 2007;  61 1-40
  Article in Thieme ConnectPubMedGoogle Scholar
• 11 Vestbo J, Anderson JA, Calverley PM et al.. Adherence to inhaled therapy, mortality and hospital admission in COPD.  Thorax. 2009;  64 939-943
  CrossrefPubMedGoogle Scholar
• 12 Faul JL, Galindo J, Posadas-Valay R et al.. An arteriovenous fistula increases exercise capacity in patients with COPD.  Chest. 2010;  138 52-58
  CrossrefPubMedGoogle Scholar
• 13 Barr RG, Bluemke DA, Ahmed FS et al.. Percent emphysema, airflow obstruction, and impaired left ventricular filling.  N Engl J Med. 2010;  362 217-227
  CrossrefPubMedGoogle Scholar

Korrespondenz

Dr. med. Andreas Jerrentrup

Klinik für Innere Medizin Schwerpunkt Pneumologie Uniklinikum Gießen und Marburg Standort Marburg

Baldingerstraße

35043 Marburg

Fax: 06421/58-68987

Email: jerrentr@med.uni-marburg.de